Analysis of Perforations During Chronic Total Occlusion PCI

Study Questions:

What are angiographic characteristics and management strategies of coronary perforations during chronic total occlusion percutaneous coronary intervention (CTO PCI)?


Data were analyzed from the 12-center OPEN-CTO registry prospectively evaluating CTO PCI in 1,000 patients in the United States. Clinical perforation was defined as any perforation requiring treatment. Major adverse cardiac events (MACE) included in-hospital death, cardiac tamponade, and pericardial effusion.


Coronary perforations occurred in 89 patients (8.9%), of which 43 (48.3%) were clinically significant and more than half were simply observed. MACE occurred in 25 (28%) and in-hospital death occurred in 9 (10.1%) patients. Larger size, proximal or collateral location, and high-risk shape of perforation was associated with adverse outcomes. The majority of perforations occurred at the time of antegrade approach (60%).


Larger size, proximal or collateral location, and high-risk shapes of a coronary perforation were associated with MACE. Six of ten perforations occurred with antegrade approaches among patients who had both strategies attempted. These findings will help emerging CTO operators understand high-risk features of the perforation that requires treatment and inform future comparisons of retrograde and antegrade complications.


Coronary perforations are the most common CTO PCI-related complications. This study is a first rigorous assessment of coronary perforations to better define mechanisms, management, and related outcomes. Larger vessel size, proximal location of perforation, and certain ‘high-risk shapes’ (seven possible angiographic shapes defined) were associated with clinically relevant perforation. Although the overall rate was approximately 9%, less than half of the perforations required intervention and the majority were managed with embolization, covered stent placement, or prolonged balloon inflation. Contrary to prior reports, in this analysis, antegrade attempts were associated with higher rates of perforation compared to the retrograde approach. In addition, risk of perforation with MACE was higher at the epicardial collateral sites, making this approach ‘a last resort’ option when planning a CTO PCI.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Pericardial Disease

Keywords: Angioplasty, Cardiac Tamponade, Coronary Occlusion, Hospital Mortality, Percutaneous Coronary Intervention, Pericardial Effusion, Stents

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